Discussion

This study summarises Australian Football players' attitudes and beliefs around LLIP, particularly the benefits of training. To our knowledge, this is the first sports injury prevention study to apply both HBM constructs associated with a relevant sports injury ecological model2 and the RE-AIM framework to inform the design of a sports injury prevention delivery plan.14 The information is important because it gives clear guidance for the targeting and delivery of exercise training programmes specifically for these players.

Overall, surveyed players had an accurate perception of football-related LLI risk that reflected the reported frequency of LLI in this sport,28,–,32 though their relative rankings of knee versus ankle injuries were different from those in the literature.29 31 33 These findings support the need for players to be educated further about the risk of knee injury specifically and also suggest that exercise interventions should be marketed as being of a more general LLIP nature rather than just focusing on knee injuries. This has implications for both the RE-AIM reach and adoption components. As most exercise training programmes that address knee neuromuscular control are also likely to benefit the rest of the lower limb,19 broadening the focus of intervention programmes for targeting purposes would still maintain biomechanical fidelity.

Only about half of all players considered that LLIs could be serious and impact on their ability to play a game, despite published information about this.34 The majority appear to recognise the potential for adverse consequences associated with continuing to play with LLIs in terms of the physical implications this may have later in life. However, there was no strong view about being fully rehabilitated from an LLI before returning to play. This suggests that players need to be better educated about the nature and extent of possible adverse LLI outcomes and that any strategy to recruit them into an RCT and maintain their engagement with exercise training practices should emphasise both LLIP and performance gains. The fact that beliefs about LLI risk and outcomes were related to player age and experience suggests that any overarching approach may need to include different education/promotion strategies for players at different stages of their football career. This has particular implications for the adoption and maintenance RE-AIM components.

Most players understood that specific training and exercises have a role in LLIP. This indicates a likely readiness of players to adopt LLIP programmes when they are embedded into standard football-training sessions. There was a difference in players with/without a previous LLI with regard to views about undertaking additional training at home, indicating that such a delivery strategy would not be adopted by all players. Nonetheless, about a third of players who were uncertain about the LLIP benefits of attending training also indicated a lack of knowledge about specific training components for reducing LLI risk; this is consistent with the level of knowledge exhibited by coaches of the same teams.7 The only other factor that players believed was more important for LLIP than performance was protective equipment use; this was rated even higher than warming up, cooling down and balance training.

Players were in strong agreement that most components of training sessions would improve performance, and the majority agreed that undertaking specific exercises would lead to LLIP. This suggests that extensive efforts aimed at educating players about the benefit of exercises/training programmes are unlikely to be needed before footballers were recruited into an exercise training RCT. However, there is still a need to educate players about the benefits of some aspects of training sessions such as skills training, ball handling and jump/landing, as many rate them as being highly important for performance but not for LLIP.

It is concerning that the vast majority of players would contemplate playing with an LLI if it was an important game, even though they did not feel under pressure to play when injured, consistent with previous findings in elite junior footballers.24 This has important implications in terms of preventing injury recurrence and rehabilitation strategies postinjury. While players recognise the long-term risk of continuing to play with injury, external factors are likely to make it difficult in reality to convince them to take time away from their sport to fully recover, particularly if they perceive their absence as detrimental to the team's performance. Given this, an effective implementation strategy would be delivered to whole teams of players, rather than just individual players, so that the benefits to the team can be stressed, and peer support could influence the adoption.

‘Barriers’ have been identified as the most powerful of the HBM components in terms of predicting a whole variety of behaviours.22 This study highlights important barriers to LLIP that would need to be addressed in the delivery of exercise interventions implemented as part of football training. The majority of players agreed that training should focus more on improving game performance than on LLIP, and while they also have a general belief in the value of exercises for LLIP, they do not want this as the major focus of their training sessions completely. This is further complicated by the clear delineation of players' beliefs as to what components of training contribute most to improved performance and which mostly to LLIP. Players are unlikely to be fooled by LLIP marketed as being performance enhancing, if there are no clear performance outcomes. It is advisable, therefore, that LLIP exercises delivered during training are acknowledged as such and have a shorter duration than training components aimed at performance and game development. Given the strong support for warming-up-type strategies for LLIP, it would seem appropriate also to place other purely LLIP training activities towards the start of training sessions.

Although the majority of surveyed players would attend a university to test their skills for LLIP, more would be willing to do so if it helped them to play better. This is important to know because specific recruitment strategies may need to be developed to encourage players to undergo further testing away from their training venue. Similarly, the majority of players would do extra training at home if they thought it would decrease their risk of LLI, but even more would do the extra training if they thought it would help them play better. Taken together, this suggests that LLIP is a strong-enough stimulus to trigger many players to undertake additional skills testing and extra training. This is good news for LLIP measures that require this kind of behaviour uptake. However, the team building and overall performance-goal findings, together with the fact that it is hard to monitor correct techniques outside formal training sessions and to provide the necessary equipment for this, mean that delivery of an intervention through formal training sessions is likely to be most acceptable to players.

This study does have some limitations that need to be acknowledged. The survey was not fully validated, though it was heavily based on similar surveys of safety behaviours in Australian Football players. Although a major strength is the fact that the survey was constructed from a theoretical basis deriving from the HBM and RE-AIM, because the questions were not structured to address a single behaviour, it was not possible to formally test the HBM theory applicability or to explore particular beliefs according to theory predictions in detail. Even though the analyses presented here would suggest that the HBM is relevant to understanding beliefs about LLI and LLIP in football players, there would be further value in formally testing the HBM in this context.

The survey was only conducted within participants of Australian Football, and it is not known to what extent the beliefs and cues to action identified in this study would apply to other sports. Similarly, the surveyed footballers were high-performance players, and it is possible that players at lower levels of competition (eg, in community clubs) could have different views. Both of these aspects of generalisation of results should be assessed in future studies.